1.2 MCP PUBLICATIONS MCP Dental Payment Schedule Newsletters Website

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1 Table of Contents 1. INTRODUCTION 1.1 OVERVIEW MCP PUBLICATIONS MCP Dental Payment Schedule Newsletters Website ROLES & RESPONSIBILITIES Role of the Newfoundland and Labrador Dental Association Role of the Newfoundland and Labrador Dental Licensing Board Role of the Department of Health & Community Services COMMITTEES Dental Monitoring Committee Dental Services Liaison Committee DOHCS ORGANIZATIONAL CHART FOR MEDICAL/DENTAL SERVICES PROGRAMS AND SERVICES 2.1 OVERVIEW CHILDREN S DENTAL HEALTH PROGRAM SURGICAL-DENTAL PROGRAM DENTAL BURSARY PROGRAM MEDICAL TRANSPORTATION ASSISTANCE PROGRAM Medical Care Plan (MCP) 1 7

2 Table of Contents 3. PROVIDER REGISTRATION 3.1 OVERVIEW NEWFOUNDLAND AND LABRADOR DENTAL LICENSING BOARD REGISTRATION CHANGES TUTORIALS MCP BILLING SOFTWARE 4.1 OVERVIEW FEATURES OF TELECLAIM Claims Submission Windows Compatibility and Minimum Requirements Electronic Billing Application Installation and Support Other Billing Software and Services FINANCIAL SERVICES 5.1 OVERVIEW QUERIES FINANCIAL STATEMENTS. 2 2 Medical Care Plan (MCP) 2 7

3 Table of Contents 6. BENEFICIARY REGISTRATION 6.1 OVERVIEW ELIGIBILITY MCP CARDS INCOME SUPPORT RECIPIENTS NEWFOUNDLAND AND LABRADOR PRESCRIPTION DRUG PROGRAM LOW INCOME RECIPIENTS INSURED SERVICES 7.1 OVERVIEW INSURED SERVICES Children s Dental Program Surgical-Dental Program Income Support NLPDP Access Plan DIFFERENCE BILLING PAYER OF LAST RESORT DENTAL CLAIMS 8.1 OVERVIEW SAMPLE CLAIMS Case 1 Pulpotomy and Restoration Case 2 Emergency Exam, X-Ray, Extraction and Restoration Medical Care Plan (MCP) 3 7

4 Table of Contents Case 3 Emergency Exam and X-Ray Case 4 Sealants Case 5 NLPDP Low Income Recipient, Restoration Case 6 Prior Approval, Emergency Exam, Periapical X-Ray, Root Canal, Crown Case 7 Surgical-Dental Case 8(A) Surgical-Dental with Specialist Assistant Case 8(B) Surgical-Dental, Specialist Assistant Case 9 Dental Specialist INDEPENDENT CONSIDERATION (IC) CLAIMS Case 1 Sample of IC Surgical-Dental Extraction of Impacted Tooth Case 2 Sample of IC Periapical X-Ray Case 3 Sample of IC Dental Surgery, General Dentist Assisting Requirements for Billing of Certain Fee Codes Indicated as IC CODING SYSTEMS Remarks Codes Tooth Codes Diagnostic Codes Hospital Codes CLAIMS PROCESSING 9.1 TIME LIMITS CUT OFF AND PAY DATES CLAIMS PROCESSING Receipt Validation Assessment Payments CLAIM REQUESTS AND NOTICES Claim Categories Turn Around Document (TAD) Requests for Information Turn Around Document (TAD) Notice of Cancellation Medical Care Plan (MCP) 4 7

5 Table of Contents 9.5 METHOD OF PAYMENT UNPAID CLAIM INQUIRIES CLAIM APPEAL PROCEDURES REMITTANCE STATEMENT ELECTRONIC MEDIA Text Remittance Statement Remittance Detail Report AUDIT OF CLAIMS 10.1 OVERVIEW DENTAL AUDIT PROGRAM Audit Initiation Indicators Beneficiary Verification Audits Complaints or Voluntary Information Audits of Targeted Fee Codes Preliminary Audit Comprehensive Audit DENTIST INTERVIEW DENTAL MONITORING COMMITTEE (DMC) NOTIFICATION OF RECOVERIES ALTERNATE DISPUTE RESOLUTION (ADR) PROCESS HEARING BY AUDIT REVIEW BOARD MINISTERIAL ORDER APPEAL TO SUPREME COURT TRIAL DIVISION Medical Care Plan (MCP) 5 7

6 Table of Contents DENTAL CLAIMS AUDIT PROCESS FLOW CHART Audit Initiation Preliminary Audit Stage Comprehensive Stage Dental Provider Interview Review by Dental Monitoring Committee (DMC) Notification Alternate Dispute Resolution (ADR) Hearing by Audit Review Board Ministerial Order Appeal to the Supreme Court Trial Division APPENDIX 1 FORMS 1. FORMS USED BY DENTAL PROVIDERS: 1.1 PROVIDER REGISTRATION FORM GUIDELINES FOR COMPLETION OF PROVIDER REGISTRATION FORM ASSIGNMENT OF PAYMENT AGREEMENT ELECTRONIC BILLING APPLICATION APPLICATION FOR RURAL DENTAL BURSARY PROGRAM APPLICATION FOR DENTAL SPECIALIST BURSARY PROGRAM REQUEST FOR RELEASE OF MCP BENEFICIARY NUMBER REQUEST FOR FORMS DENTAL PAPER CLAIM FORM DENTAL INDEPENDENT CONSIDERATION (I.C.) CLAIM FORM DENTAL PRIOR APPROVAL FORM Medical Care Plan (MCP) 6 7

7 Table of Contents 2. FORMS USED BY BENEFICIARIES: 2.1 APPLICATION FOR NEWFOUNDLAND & LABRADOR HEALTH CARE COVERAGE NEWBORN/ADOPTED CHILD REGISTRATION FORM CHANGE OF NAME FORM CARD REPLACEMENT FORM NLPDP APPLICATION FOR ACCESS PLAN APPLICATION FOR MEDICAL TRANSPORTATION ASSISTANCE OUT-OF-PROVINCE CLAIM FORM APPENDIX 2 DIAGNOSTIC CODES APPENDIX 3 HOSPITAL/FACILITY CODES APPENDIX 4 ABBREVIATED TERMS DENTAL PAYMENT SCHEDULE GENERAL PRACTITIONERS DENTAL PAYMENT SCHEDULE SPECIALISTS SURGICAL-DENTAL PAYMENT SCHEDULE Medical Care Plan (MCP) 7 7

8 Introduction 1. INTRODUCTION 1.1 OVERVIEW The purpose of this Information Manual is to provide instructions on the preparation and the submission of dental claims for services insured under the Medical Care Plan and Dental Health Programs. This document contains instructions on the completion of claims, the handling of queries on previously submitted claims, information on the payment process, sample claims for various services, information on dentist and beneficiary registration, and the Medical Care Insurance Act, etc. This document is not intended to replace the MCP Dental Payment Schedule it deals mainly with the process required for the submission of claims. If there is conflicting information, the MCP Dental Payment Schedules will prevail. This document will be amended as necessary and new material or revisions to policies and procedures will be added to the document on the website at under the topic Information for Providers. When new material is added or edits made to existing information, MCP will send out a Newsletter informing dental providers of the specific changes to this document on the website. 1.2 MCP PUBLICATIONS The following MCP publications are available upon request and are designed for your benefit. Please contact MCP at or (709) if you wish to obtain a copy of any of these documents: MCP Dental Payment Schedule This document identifies the amounts prescribed as payable and rules and conditions of payment under the Physicians and Fee Regulations (Schedule A), governed by the Medical Care Insurance Act for insured services rendered by licensed dental providers. Amendments are mailed periodically and should be entered in the appropriate section of the Payment Schedule. The Payment Schedule is also available for download on the internet at under the topic Information for Providers. The Dental Payment Schedules can also be found in this Dental Information Manual. Medical Care Plan (MCP) 1 8

9 Introduction Newsletters MCP issues newsletters periodically to make dental providers aware of various matters such as claim processing period cut-offs, Payment Schedule amendments, etc. These are sent to all or to specific groups of dental providers depending on the topic. Access to MCP Newsletters is also available on the internet at under the topic Information for Providers. All Newsletters received should be read carefully to determine their impact on your practice. If the content of a newsletter is not clearly understood, you should contact MCP for clarification Website The Newfoundland and Labrador Medical Care Plan website can be found at Website contents include: Am I Covered? Provider Information Forms Medical Claims History Contact MCP Medical Care Act Dental Health Plan Medical Travel Assistance Family Physicians Who Are Accepting New Patients - The College of Physicians and Surgeons of Newfoundland and Labrador provides assistance with finding family physicians accepting new patients. Other Health Sites Medical Care Plan (MCP) 2 8

10 Introduction 1.3 ROLES AND RESPONSIBILITIES Role of the Newfoundland and Labrador Dental Association (NLDA) The Newfoundland and Labrador Dental Association serves the interests and goals of its Members through advocacy, professional development and knowledge exchange to advise the dental profession and represents the dental profession both provincially and nationally. It is the NLDA s objective to promote and advance dentistry, to increase the knowledge, skill, standard and proficiency of its Members in the practice of dentistry and to maintain the honor and integrity of the dental profession. The NLDA works in close cooperation with Government to establish reasonable salary levels for Salaried Dentists, to establish fee levels for Government sponsored Dental Programs and to assist Government to develop program and policy as it relates to oral health in the Province. By agreement the NLDA and the Department of Health and Community Services will meet as least once quarterly to discuss items related to the provision of Oral Health services in the Province. The location and contact information is: The NLDA The Fortis Building Suite 401,139 Water Street St. John s, NL A1C 1B2 Telephone: Fax: nfdental@nfld.net Website: Medical Care Plan (MCP) 3 8

11 Introduction Role of the Newfoundland and Labrador Dental Licensing Board The Newfoundland and Labrador Dental Board is the body that endeavors to act on behalf of the public to maintain access to a safe dental service in the province. Also, the Board hopes to ensure that those persons who provide such services are properly trained and continue to maintain a satisfactory level of competence appropriate to their individual license. Roles and Responsibilities The Board shall maintain a register of all license holders and it shall be open to viewing by the public at all reasonable times. The Board shall be responsible for determining matters pertaining to the disciplining of license holders and will act to address all complaints. The Board shall make by-laws including the establishment of a Code of Ethics. The Board shall establish standards for the practice of dentistry, including standards of professional competence and of capacity and fitness to practice. The Board may make regulations respecting the education and practice experience requirements for the registration of Dentists and Dental Auxiliaries as approved by the Dental Act The Board shall be responsible for the registration and licensing of Professional Corporations. The Board shall make regulations defining dental auxiliaries, prescribing their qualifications and the services they may provide. The Board shall generally act to give effect to the Dental Act 2008 and its Regulations but also respect in principle and in action all other laws that may govern the province. Medical Care Plan (MCP) 4 8

12 Introduction Role of the Department of Health and Community Services (DOHCS) The Minister of Health and Community Services is responsible for the administration of the Medical Care Plan and the Dental Health Plan. The DOHCS, on behalf of the Minister, is responsible for the formulation of policy as well as decisions with respect to legal and financial matters associated with the operation of the Plans. An organizational chart depicting MCP operations has been included at the end of this section. The Audit and Claims Integrity Division (ACID), under the direction of the Executive Director, is responsible for the overall operation of both Plans, and reports to the Assistant Deputy Minister, Corporate Services Branch, of the DOHCS. The administrative offices, management and staff within this Division that deal directly with the service delivery and auditing of both Plans, is commonly referred to as MCP. The Regional Director (Grand Falls-Windsor) is responsible for the day to day operation of the Grand Falls-Windsor office of MCP, including full responsibility for Claims Operations and administrative responsibility for Public Services. The Claims Operations section is responsible for the processing and assessing of medical and dental claims, as well as participating in the production of various manuals (Physician Payment Schedules, Dental Payment Schedules, etc) related to the operation of the Plans. Public Services is responsible for the registration of beneficiaries and the issuance of MCP cards. The Director of Dental Services is accountable for providing dental expertise to the Medical Services Branch of the Department of Health and Community Services with respect to the administration of the Dental Health Plan and the Surgical Dental Program and in matters relating to dentistry in accordance with established departmental policies and programs. 1.4 COMMITTEES Dental Monitoring Committee (DMC) Terms of Reference The Dental Monitoring Committee shall be appointed by the Department of Health and Community Services (DOHCS) and shall consist of a minimum of five members, three of whom shall be from the Newfoundland and Labrador Dental Association (NLDA), one from the DOHCS, and the Dental Director of MCP who will act as Chairperson. Medical Care Plan (MCP) 5 8

13 Introduction Appointments will be reviewed on a three year cycle, with no maximum consecutive terms. The Committee shall meet at the discretion of the Chairperson. (Quarterly meetings are expected to be the norm, but additional meetings can be called to address extra workload or to receive Committee input on issues relating to the Newfoundland and Labrador Dental Plan.) Results of Committee meetings will be relayed to the DOHCS (MCP) through the Chairperson. The Committee shall be assigned the responsibility of reviewing and settling contentious or complex claims which are referred through the Dental Director. The Committee may make recommendations to the DOHCS (MCP) on policy issues where it is deemed appropriate. The representatives will be remunerated in accordance with established Committee rates. Out of town members will be reimbursed for travel expenses Dental Services Liaison Committee Terms of Reference Purpose: To establish a mechanism through which dental issues of mutual concern may be addressed collaboratively between Newfoundland and Labrador Dental Association (NLDA) and the Department of Health and Community Services (DOHCS), and to provide advice to the Minister related to these issues. Membership: The membership shall consist of three members from NLDA and three members from DOHCS. The Committee shall be co-chaired and shall alternate between NLDA and DOHCS. The Deputy Minister of the DOHCS and the NLDA shall agree on the chair for the initial meeting. The co-chairs shall then be chosen by the members of each representation. Frequency of Meetings: Meetings shall be held quarterly or at the call of the chairs for urgent issues that may arise between regular meetings. Quorum: Two members from NLDA and two members from the DOHCS shall constitute a quorum. Medical Care Plan (MCP) 6 8

14 Introduction Record of Decisions: A Record of Decisions shall be kept for all meetings. Otherwise, all discussions at the meetings shall be confidential, and there shall be no recordings of such discussions. Official recorded decisions shall be available to the Minister, the Deputy Minister, the Executive for the DOHCS, and the Executive Committee of the NLDA. Voting: All decisions of the Committee shall be made by consensus of both parties. Both parties will reserve the right to consult with their officials. Location: The time and location of the meetings shall be at the call of the Chairs. Mandate To provide information and/or advice to the Minister on dental issues from a policy, systemic and strategic perspective. To generally explore options that would contribute to a sustainable health care system, and in particular, a sustainable public dental program, that maintains and/or enhances quality of services that is reasonably accessible to all. To create sub-committees as needed to review, analyze and provide advice on issues pertaining to the Newfoundland and Labrador Dental Program. To review the current policies and procedures between the NLDA and the DOHCS regarding professional services provided by NLDA members to clients of the dental programs. The Department will also use the Committee as a forum to consult with the NLDA on other policy matters, eg. Primary Health Care renewal. Issues of an operational nature are considered outside the mandate of the Committee and should first be directed through normal channels for resolution. Medical Care Plan (MCP) 7 8

15 Introduction 1.5 DOHCS ORGANIZATIONAL CHART FOR MEDICAL/DENTAL SERVICES While there is no direct reporting structure between the Medical Services branch and the Audit & Claims Integrity division of MCP in Grand Falls-Windsor, considerable policy direction from the offices within the Medical Services branch is provided to the MCP managers in the Audit & Claims Integrity division in Grand Falls-Windsor. Medical Care Plan (MCP) 8 8

16 Programs & Services 2. PROGRAMS & SERVICES 2.1 OVERVIEW This section outlines a list of programs and services available under the Dental Health Program and the Surgical Dental Program. It also contains the Bursary program information for dental providers. 2.2 CHILDREN S DENTAL HEALTH PROGRAM The Children s Dental Health Program provides universal access for eligible dental services for children age 12 years and under as well as for children age 13 to 17 years whose families are in receipt of Income Support benefits. Coverage is automatic for these children. Coverage also includes 13 to 17 year olds living in families with low incomes. Families, who are not in receipt of Income Support, qualify under this new category. These families must first apply for coverage through the Newfoundland and Labrador Prescription Drug Program. A list of services covered can be found in Section7 Insured Services. An example of the application form can be found in Appendix 1 Forms. Services are only covered by the Dental Health Plan if they are received in Newfoundland and Labrador. 2.3 SURGICAL-DENTAL PROGRAM The provincial Surgical-Dental Program is a component of the Medical Care Plan (MCP). Surgical-dental treatments provided to a beneficiary and carried out in a hospital by a licensed oral surgeon or dentist are covered by MCP if the treatment is specified in the Surgical-Dental Services Schedule. All oral surgeons or dentists licensed to practice in Newfoundland and Labrador and who have hospital privileges are allowed to provide surgical-dental services. The dentist s license is issued by the Newfoundland and Labrador Dental Board. Because the Surgical-Dental Program is a component of the MCP, management of the Program is linked to the MCP process regarding changes to the list of insured services. Medical Care Plan (MCP) 1 3

17 Programs & Services Addition of a surgical-dental service to the list of insured services must be approved by the Minister. 2.4 DENTAL BURSARY PROGRAM The Department s Dental Bursary Program has two components, the Rural Dental Bursary Program and the Specialist Bursary Program. Students must apply annually for bursaries and are eligible to receive a maximum of three bursaries. In exchange for each bursary received, bursary recipients are required to commit to one year of service in rural or in-need areas of the province. Recipients of the Rural Dental Bursary are required to fulfil their practice commitment in a rural area determined by the province. These areas have been designated and prioritized through discussions between the Department of Health and Community Services, the Newfoundland and Labrador Dental Association, the Newfoundland and Labrador Dental Licensing Board, and the Regional Health Authorities. An example of the Application for Rural Dental Bursary Program can be found in Appendix I Forms. For the Specialist Bursary Program, applicants are required to work in areas where specialists can practice upon graduation. Examples of dental specialists include endodontists, periodontists, oral surgeons, prosthodontists and orthodontists. An example of the Application for Dental Specialist Bursary Program can be found in Appendix I Forms. Recipients will be determined through a competitive application process and while the program is open to Canadian citizens, preference is given to students from Newfoundland and Labrador. To be eligible, an applicant must be accepted into an accredited dental program recognized by the Newfoundland and Labrador Dental Licensing Board. The awarding of bursaries will be determined by a committee comprised of Provincial Government representatives and members of the Newfoundland and Labrador Dental Association. For the most recent list of under-serviced areas please contact the Director of Dental Services at (709) Medical Care Plan (MCP) 2 3

18 Programs & Services 2.5 MEDICAL TRANSPORTATION ASSISTANCE PROGRAM The Medical Transportation Assistance Program provides financial assistance to residents of the province who must travel for insured services not available within their place of residency and/or province. This program applies to services that are insured under the Surgical Dental Program but are not available in the province of Newfoundland and Labrador. Applications must be submitted for eligibility prior to leaving the province. See Appendix I for an example of the application form. The Medical Transportation Assistance Application form can also be found on the MCP website at The Medical Transportation Assistance Program is only applicable to the Oral Surgery Program. The Children s Dental Program does not qualify as this program is not portable outside the province of Newfoundland and Labrador. Medical Care Plan (MCP) 3 3

19 Provider Registration 3. PROVIDER REGISTRATION 3.1 OVERVIEW In order to submit claims for services insured under the Newfoundland Medical Care Insurance Act, providers must be registered with MCP. Upon registration, a dental provider is assigned a six-digit provider number for billing purposes. This number will be your unique identifier and must be quoted on all claims and correspondence sent to MCP. A Provider Registration Form is used to obtain the necessary information to register a dentist or dental surgeon. This form can be used for initial registration, re-activation of a previous registration, or for changes to information previously given to MCP. The registration form, along with completion instructions, can be found in Appendix 1 Forms. 3.2 NEWFOUNDLAND AND LABRADOR DENTAL LICENSING BOARD In order to be registered by MCP, a dentist or dental specialist must be registered with the Newfoundland and Labrador Dental Licensing Board and assigned a unique registration number. This number should be entered on the registration form or arrangements made with the association to have the number and other licensing information sent in writing to MCP. 3.3 REGISTRATION CHANGES It is extremely important that registration information on file with MCP be kept current. MCP Physician Services should be notified of any changes in registration information. This is done by submitting an updated Provider Registration form. Failure to do this could result in a number of problems such as: claim payment delayed payments deposited to an incorrect bank account unnecessary queries on claims submitted correspondence sent to an outdated address Medical Care Plan (MCP) 1 2

20 Provider Registration Provider registration changes can be mailed or faxed to: Medical Care Plan Medical Services Department of Health & Community Services Belvedere Building, 57 Margaret s Place P.O. Box 8700 St. John s, NL A1B 4J6 Telephone: (709) Fax: (709) TUTORIALS Training is available and strongly recommended to dental providers and their staff for instruction and education on MCP billing, the Payment Schedule and other tools necessary to submit claims to MCP, i.e. electronic billing program, TeleClaim. For information about this service, please contact our Claims Processing Division at Medical Care Plan (MCP) 2 2

21 MCP Billing Software 4. MCP BILLING SOFTWARE 4.1 OVERVIEW MCP has developed its own claims preparation and reconciliation software, TeleClaim, which allows dental providers to electronically prepare claims for medical and dental services. It is available free of charge from MCP, by calling MCP Operations at (709) TeleClaim training is also available by calling Medical Affairs & Training at (709) or TeleClaim enables: Submission of fee-for-service surgical-dental and dental claims to MCP Processing of turn-around documents (TAD s) for fee-for-service dental claims TeleClaim can be used either on a stand alone computer or in a network environment. Because of the diversity of network environments, it is recommended you seek the assistance of a computer professional for installation and support. It is also recommended that users have some training and/or experience in working with computers. (eg. using Windows Explorer, copying files from a CD, etc). TeleClaim performs limited edit checks on the data entered for each claim. It is the responsibility of the user to ensure that claim information is accurate. TeleClaim must be used in conjunction with MCP s transmission software package. All dental providers must send and receive data via MCP transmission software, whether TeleClaim or another billing software package is used. 4.2 FEATURES OF TELECLAIM Claims Submission Data entry for fee-for-service dental claims and letters Submission file, remittance file, and outstanding claim reports TAD patient information, electronic replies on TADS, diagnostic codes, fee codes Utilities for purging files and data, compacting the database Fee-for-service dental claims reconciliation Help function Medical Care Plan (MCP) 1 3

22 MCP Billing Software Windows Compatibility and Minimum Requirements (for a stand alone computer with a low volume of claims) Information on Windows compatibility and minimum computer requirements to run MCP software is available from MCP Operations by calling or online at It is helpful for users to have access to an system as this can help speed up support from MCP Electronic Billing Application Physicians who wish to submit claims electronically must complete and submit an Electronic Billing Application. A sample of this form can be found in Appendix 1 Forms. This application is also available online at in the Forms section, or from MCP Operations Installation and Support MCP will provide TeleClaim support by telephone, however, we do not supply hardware or software support for other software packages, or for problems resulting from machine errors or operating environments. We recommend you seek the assistance of a computer professional for installation and support. MCP can provide only minimal assistance for network environments. You may obtain a list of computer support companies from MCP Operations (online at Medical Care Plan (MCP) 2 3

23 MCP Billing Software Other Billing Software and Services Private vendors that have their own MCP billing and office management software are also available to assist providers with their electronic claim submission requirements. These private vendors, as well as some private billing services are listed under the link Medical Care Plan (MCP) 3 3

24 Financial Services 5. FINANCIAL SERVICES 5.1 OVERVIEW The Financial Services Division of the DOHCS is responsible for the final step in the claims processing stream. It is the responsibility of this Division to administer the bi-weekly payments; process payments under various block-funded, alternative funding arrangements; process claim adjustments that cannot be processed through the claims processing system and process retroactive fee payments as required. 5.2 QUERIES All cheques and direct deposits are controlled centrally by the Expenditure Control and Compliance Division of the Comptroller General s Office, Department of Finance. Inquiries to this office may be directed to the following address; apinquiries@gov.nl.ca. However, it is recommended that payment inquiries should first be directed to the appropriate DOHCS staff as noted below. Manager of Accounting Services Accounting Services Section Financial Services Division Department of Health & Community Services P.O. Box 8700 St. John s, NL A1B 4J6 (709) Accounting Clerk II Accounting Services Section Financial Services Division Department of Health & Community Services P.O. Box 8700 St. John s, NL A1B 4J6 (709) Alternate contact (709) Medical Care Plan (MCP) 1 2

25 Financial Services 5.3 FINANCIAL STATEMENTS Fee-for-service dental providers are self employed operating in either sole practitioner or group practices operating at arms length to Government. It has been noted that many practices have incorporated as allowed under the Dental Act, Government has no legal obligation to provide statements of earnings (or T4's) to self employed individuals, limited companies or incorporated legal entities. All MCP claim details and financial adjustment information is provided to dental providers in the biweekly remittance statements. Production of remittance statements is detailed elsewhere in this manual, refer to Section 9.8 Claims Processing, Remittance Statement Electronic Media. Medical Care Plan (MCP) 2 2

26 Beneficiary Registration 6. BENEFICIARY REGISTRATION 6.1 OVERVIEW To be eligible for insured services under the Medical Care Plan, a resident must be registered with the Plan and must possess a health care identity card. MCP has specific rules which determine a resident's eligibility for registration and coverage. A list of these rules is available by request. Generally, people who visit the MCP office, and who meet the eligibility requirements for registration, are issued a health care identity card immediately. In some cases there may be a delay while identity and eligibility documents are verified. Parents of newborns are usually issued registration forms at the hospital where the children are born. Parents must complete these forms and forward them to MCP=s Public Services section to complete the registration process and to obtain their child=s MCP card. As a convenience to the general public, we provide various registration forms to dental offices for patient use. We suggest that you keep an adequate supply of these forms on hand. Replacement forms may be obtained from MCP by completing and returning the Reorder Form provided for this purpose. Access to MCP forms is also available on the internet at under the Forms link. Examples of forms used for Beneficiaries can also be found in Appendix I Forms. 6.2 ELIGIBILITY Health care cards, or MCP cards, as they are usually known, are issued to each beneficiary who registers under the Plan. For further details on eligibility requirements, please refer to our website at under the Eligibility link. 6.3 MCP CARDS In May 2006, the DOHCS began issuing a new version of the MCP Card (see next page). The card contains several new features such as an expiry date, date of birth, gender and valid from date. As of July 31, 2007 the Newfoundland and Labrador Medical Care Plan will no longer accept claims made under the old MCP Cards for payment of services. As well, no payments will be approved for claims where the date of service is after the expiry date on the new MCP card. Medical Care Plan (MCP) 1 4

27 Beneficiary Registration Sample of new MCP cards Valid May, 2006 Valid January, 2008 Samples of previously issued MCP cards, but no longer valid as of July 31, 2007 Medical Care Plan (MCP) 2 4

28 Beneficiary Registration 6.4 INCOME SUPPORT RECIPIENTS The Children s Dental Health Program provides universal access for eligible dental services for children 12 years of age and under, as well as children years old whose families are in receipt of Income Support benefits. Example of Income Support Recipient Card for Dental Services 6.5 NEWFOUNDLAND AND LABRADOR PRESCRIPTION DRUG PROGRAM LOW INCOME RECIPIENTS On September 1, 2007 coverage was expanded to provide dental services for children aged years who are covered under the Access Plan component of the Newfoundland & Labrador Prescription Drug Program (NLPDP). Low income families with children who are not in receipt of Income Support may qualify under this new category which is called The Access Plan. These families must first apply for coverage through the Newfoundland and Labrador Prescription Drug Program (see Appendix I for an example of the application form). This form is available at pharmacies, dental offices or accessed on the Newfoundland and Labrador Prescription Drug Program website at or by calling Medical Care Plan (MCP) 3 4

29 Beneficiary Registration Example of NLPDP Dental Health Program Beneficiary Eligibility Letter Medical Care Plan (MCP) 4 4

30 Insured Services 7. INSURED SERVICES 7.1 OVERVIEW The services covered, or insured, under the Newfoundland and Labrador Medical Care Plan (MCP), are listed in the Dental Payment Schedule. The authorization for this coverage is contained in the Insured Services Regulations made by the Provincial Cabinet in accordance with the Newfoundland Medical Care Insurance Act. 7.2 INSURED SERVICES The Newfoundland and Labrador Dental Health Plan comprises of a Children s Dental Program component, Surgical-Dental component, an Income Support component and Low Income component The Children s Dental Program covers the following dental services for all children, up to and including age twelve: examinations (at 6 month intervals) cleanings (at 12 month intervals) fluoride applications (ages 6 to 12 at twelve month intervals), except in areas where the School Rinse Program is in place x-rays (with some limitations) routine fillings and extractions other specific procedures which require approval before treatment The Surgical-Dental Program covers the following dental services: certain surgical-dental procedures which are medically necessary to be performed in hospital by a dentist or oral surgeon Services are also available under the Income Support component to recipients of Income Support who are 13 to 17 years of age: examinations (every 24 months) x-rays (with some limitations) routing fillings and extractions emergency examinations, when patient seen for pain, infection or trauma Medical Care Plan (MCP) 1 3

31 Insured Services Adult recipients of Income Support are eligible for emergency examination as a result of pain, infection or trauma and extractions only NLPDP Access Plan Coverage also includes 13 to 17 year-olds living in families with low incomes (as specified in the Programs & Services section 6.5) who have qualified under the Newfoundland and Labrador s Prescription Drug Program Access Plan are able to receive the following services: examinations (every 24 months) x-rays (with some limitations) routing fillings and extractions emergency examinations, when patient seen for pain, infection or trauma Services are only covered by the Dental Health Plan if they are received in Newfoundland and Labrador. 7.3 DIFFERENCE BILLING Difference billing applies to parents who have dental insurance. In the example of 80/20 dental coverage, the dentist will invoice MCP 20% of the fee listed in the MCP Payment Schedule for each service rendered. The dentist will invoice the insurer or the parent the full 100% for services provided. There are two possible scenarios: a) If the dentist invoices the insurer directly and the insurer provides payment that is less than 80% of the MCP rate, the dentist may invoice the parent for the difference. This amount is called Difference Billing. b) If the dentist invoices the parent directly, the parent will pay the dentist the total 80% and will seek reimbursement from their insurer for the amount permitted under their policy. If there is a difference between what the parent pays the dentist and what they receive from their insurer, the parent will be responsible for this amount. Medical Care Plan (MCP) 2 3

32 Insured Services Insurance companies vary in the percentage they cover. If a parent/guardian has dental insurance, the dentist will determine the percentage of coverage paid by the insurer. For example, the dentist may determine that a parent has dental insurance that provides 80/20 coverage; in this case, the percentage not covered by the insurer (i.e. 20%) must be invoiced directly to MCP. The dentist will not require the parent to pay this amount and then seek reimbursement from MCP refer to the Dental Payment Schedule for applicable amount. In such cases where parent/guardian does not have dental insurance, the dentist will invoice MCP the full amount of the listed fee in the MCP Dental Payment Schedule for that service. The parent will not be invoiced any amount. Please refer to the Dental Payment Schedule, page A PAYER OF LAST RESORT Government will be the payer of last resort for insured dental services under the Dental Health Plan. Medical Care Plan (MCP) 3 3

33 Dental Claims 8. DENTAL CLAIMS 8.1 OVERVIEW This section contains instructions covering the completion of the dental claim form. This form is to be used for claims submitted under both the Dental Health Plan and the Surgical-Dental Program which is part of the Medical Care Plan. Each field on this sample has been described on the following pages. A more detailed overview of this claim entry screen may be found in the AHELP@ function of TeleClaim 6.0. Dental Provider Number: This is the dental provider s MCP billing number, which is assigned by MCP when the dental provider completes the MCP registration process. Dental Provider Name: This is the name of the dentist providing the services. Medical Care Plan (MCP) 1 29

34 Dental Claims Patient ID: This is the patient=s MCP number. Claims submitted without patient identity numbers cannot be processed for payment. Your office staff should remind patients to bring their cards to all appointments and should ask every patient to show his/her card upon arrival. If the patient does not provide his/her MCP card, it is the provider's option to bill that patient directly. Patient Surname: This information is not required to be submitted to MCP; however, most billing software, including TeleClaim 6.0, captures this information as an office management tool. Patient Given Names: This information is not required to be submitted to MCP; however, most billing software including TeleClaim 6.0 captures this information as an office management tool. Income Support Number: This information is required for all Income Support clients. Claims submitted without this number will not be processed for payment. Income Support File Number: This information is required for all Income Support clients. Claims submitted without this number will not be processed for payment. Service Date: The date insured services were provided to the patient. Birth Date: The patient=s date of birth. Province: The patient=s home province. Sex: The gender of the patient. Diagnostic Code: This section is optional for the Dental Health Plan but must be completed for surgical-dental claims. Fee Code: This is the fee code associated with the dental service provided to the patient, as listed in the MCP Dental Schedule. Units: This is the number of units of the dental service provided to the patient. For time based services, one unit is defined as a specific time period corresponding to a specific service/procedure, as listed in the MCP Dental Schedule. Fee Claimed: This is the fee amount that corresponds to the fee code listed in the MCP Dental Schedule, with Preamble rules applied. Remarks Code: This code should be entered if it is necessary to make MCP aware of some Medical Care Plan (MCP) 2 29

35 Dental Claims pertinent information regarding the claim. Refer to Coding Systems Remarks Codes in this section for a list of appropriate Remarks Codes to enter in this field. If there is no applicable fee code listed and it is necessary to convey additional information, the item must be billed AIC@. Capacity: This is the capacity of the dentist providing the services. The appropriate capacity codes are as follows: o Dentist/Oral/Surgeon 0 o Assistant 1 o Anaesthetist 3 Referral Code: This must be completed by all specialists in order to be paid the specialty rate for procedures. The appropriate referral codes are as follows: o Non-referred 1 o Referred 2 Hospital/Facility Number: This section must be completed for surgical-dental claims only as applicable. Enter a four digit code for the applicable hospital as per the list of hospitals in Appendix 3 Hospital Codes. Payee Number: This area indicates to whom payment will be made for the service provided. If payment is assigned to another dental provider or institution please ensure the payee field is completed to appropriately reflect the payee number. An Assignment of Payment Agreement must be on file at MCP if payment is assigned to another dental provider or institution. Please refer to Appendix 1 Forms, for an example of the Assignment of Payment Agreement form. The payee number must contain six digits. Therefore, if a three digit institution number is used as a payee number, then zeros must be added in front of the three digit number to make it a six digit number, eg. institution number 999 would be entered as Independent Consideration (IC): An entry into this field alerts MCP that the claim requires manual assessment. Some items in the Payment Schedule are flagged as IC and must be billed as such. Also, when a service rendered is not listed in the Dental Schedule, it must be labelled IC. If the claim is being submitted for Independent Consideration, an X must be entered in this field. Additional information supporting the claim must be entered in the AComments@ section of the claim. Failure to comply with both of these issues could result in the claim being returned to the dental provider. Medical Care Plan (MCP) 3 29

36 Dental Claims 8.2 SAMPLE CLAIMS The following pages contain samples of completed claims for several categories of services. These are designed to illustrate the use of various fee codes used within the system and their relationship to the claim data. The dentists', patients' names, and numbers are fictitious. In the following cases, the fee codes and amounts may not correspond with the current Dental Schedule. Claims for services should be prepared using the current dental rates. The examples are illustrated using MCP=s TeleClaim 6.0. Your claims entry screen may look different if using other billing software. However, the principles of completing the claim will remain the same Case 1 Pulpotomy and Restoration An eight year old boy, James W. Howse, visits Dr. Cindy Brown on May 3, 2010 for two fillings. One tooth (74) requires a pulpotomy and an MOD restoration and the second tooth (36) requires an MO restoration. Fee Codes Used and Fees Claimed by Dr. Brown: Restoration, three surfaces, fee code at $109.54, tooth 74, surface code MOD Pulpotomy, fee code at $60.38, tooth code 74 Restoration, two surfaces, fee code at $106.46, surface code MO, tooth code 36 Case 1 Screen 1 of 3 Medical Care Plan (MCP) 4 29

37 Dental Claims Case 1 Screen 2 of 3 Case 1 Screen 3 of 3 Medical Care Plan (MCP) 5 29

38 Dental Claims Case 2 Emergency Exam, X-Ray, Extraction and Restoration A 14 year old boy, Robert Wells, a recipient of Income Support, visits Dr. S. Woods on August 18, 2010 complaining of a toothache. Upon examination and the taking of a periapical x-ray, Dr. Woods discovers his patient requires an extraction, tooth 16, and one filling, tooth 14, MOD restoration. These procedures are then performed. Fee Codes Used and Fees Claimed by Dr. Woods: Emergency examination, fee code at $ Remarks Code 63 is entered on claim to indicate patient in pain One periapical x-ray, fee code at $ A Remarks Code is required. In this case, Remarks Code 63 is acceptable Extraction, fee code at $84.29, tooth 16 Restoration, three surfaces, at $142.64, tooth 14, surface code MOD As patient is an Income Support recipient, the valid Income Support Identification Number must be included on the claim as well as the Income Support File Number. Case 2 Screen 1 of 4 Medical Care Plan (MCP) 6 29

39 Dental Claims Case 2 Screen 2 of 4 Case 2 Screen 3 of 4 Medical Care Plan (MCP) 7 29

40 Dental Claims Case 2 Screen 4 of 4 Medical Care Plan (MCP) 8 29

41 Dental Claims Case 3 Emergency Exam and X-ray On June 2, 2010 a ten year old boy, Joey White, is seen by Dr. Brown as a follow up visit to trauma. Dr. Brown also takes a periapical x-ray to assess possible tooth fracture. Fee Codes Used and Fees Claimed by Dr. Brown: Specific oral examination, fee code at $ This fee code requires a Remarks Code 66 to indicate follow-up visit to trauma to be entered on claim One periapical x-ray, fee code at $ This fee code requires Remarks Code 80 to indicate checking for possible tooth fracture Case 3 Screen 1 of 2 Medical Care Plan (MCP) 9 29

42 Dental Claims Case 3 Screen 2 of 2 Medical Care Plan (MCP) 10 29

43 Dental Claims Case 4 Sealants An 11 year old boy, James Brown, saw Dr. John White to have sealants done on two permanent molars. Fee Codes Used and Fees Claimed by Dr. White: Fee code billed for first sealant at $24.34, tooth 36, surface code O Fee code billed for additional tooth at $14.87, tooth 37, surface code O Case 4 Claim 1, Screen 1 Medical Care Plan (MCP) 11 29

44 Dental Claims Case 4 Claim 2, Screen 1 Medical Care Plan (MCP) 12 29

45 Dental Claims Case 5 NLPDP Low Income Recipient, Restoration Dr. White sees 15 year old Sally Smith, who is a NLPDP Low Income Support Recipient, and requires a two surface restoration. Fee Codes Used and Fees Claimed by Dr. White: An eligibility letter is provided to Low Income Support recipients by NLPDP that must be presented to the dental provider prior to claim submission. This NLPDP eligibility letter must be mailed or faxed to MCP at (709) comments should be included on the electronic claim indicating NLPDP eligibility letter has been sent to MCP Restoration, two-surface fee code billed at $ indicating tooth number (25) and surfaces (MO) restored. Case 5 Screen1 of 1 Medical Care Plan (MCP) 13 29

46 Dental Claims Case 6 Prior Approval, Emergency Exam, Periapical X-Ray, Root Canal, Crown On October 14, 2010, Mary Whelan, 12 years old, required dental treatment following an accident where she fell and fractured the crown of tooth 11. Dr. Woods does an emergency exam including a periapical x-ray. Findings confirm that the tooth crown is fractured but the root is intact. The tooth requires a root canal, post and core and porcelain jacket crown. Dr. Woods requests a Prior Approval (P.A.) from MCP for these procedures and receives same with P.A. # for billing purposes. The root canal is completed on November 8, 2010 and the post and core and porcelain crown on December 14, Dr. Woods has made arrangements with MCP to have Dr. John White receive payment on his behalf, as a payee. Fee Codes Used, Fees Claimed and procedures followed by Dr. White: Claim 1 October 14, 2010 Emergency examination, fee code at $ Remarks Code 65 is required patient seen as a result of trauma Periapical x-ray, fee code at $ Remarks Code 65 is also required for this procedure Request for Prior Approval to MCP for the procedures required. An example of a Dental Prior Approval request form can be found in Appendix I Forms. Claim 2 November 8, 2010 Root canal, fee code at $388.59, tooth code 11 Prior Approval number must be quoted on claim Claim 3 December 14, 2010 Cast post and core, fee code at $268.70, tooth code 11 Porcelain jacket crown, fee code at $622.86, tooth code 11 Laboratory bill, fee code was billed at $250, tooth code not required Prior Approval number must be quoted on claims Medical Care Plan (MCP) 14 29

47 Dental Claims Case 6 Claim 1, Screen 1 Case 6 Claim 1, Screen 2 Medical Care Plan (MCP) 15 29